Despite our best efforts, every year 480,000 Americans continue to die from smoking. And, for the majority of our citizens, including healthcare professionals and policymakers, the solution to this problem is singular: Tell people to quit smoking.

To wit, the Office of Disease Prevention and Health Promotion issued recommendations to achieve its goal of shrinking tobacco-use numbers from 20 percent in 2008 to 12 percent by 2020. The recommendations consist almost exclusively of abstinence-only interventions: anti-tobacco public health campaigns, Medicaid coverage for quit-aids, quitting incentive programs, and increased capacity for smoking quitlines.

These interventions have been shown to reduce tobacco use in populations that disproportionately use tobacco – to a point. For example, after Massachusetts adopted Medicaid coverage for quit-aids, its smoking rates dropped by 10 percent in two years. But the smoking rate among Medicaid recipients is still almost double the national average. And nationally, although the smoking rate has declined since 2008, the rate did not decrease between 2015 and 2016. This suggests we may have hit a plateau.

It seems, then, that public health wins using a quit-or-die approach can only take us so far.

The good news is that there are many ways to reduce smoking rates, and reducing demand for tobacco is just one of those ways. To be sure, it’s a very good way. But one has to wonder if it should be a standalone approach, or if it’s even the best approach, to combating smoking-related disease and death.

This is where tobacco-control enthusiasts can learn a valuable lesson from how we are addressing the opioid epidemic. Last year, the White House Commission on Combating Drug Addiction and the Opioid Crisis issued an interim report. Like the ODPHP’s tobacco recommendations, the commission’s report focuses on prevention and abstinence as ways to help people overcome opioid addiction. Yet unlike ODPHP’s recommendations, the commission’s plan also includes two nontraditional methods of combating risk behaviors: decreasing barriers to medication-assisted treatments and increasing naloxone access.

These harm-reduction approaches to risk behaviors offer a promising alternative to abstinence-only programs. Rather than insisting that the only way to avoid the problem is to encourage people to just say “no,” these methods aim to decrease specific, harmful consequences of those behaviors, like disease and death.

Historically, harm-reduction approaches have had a positive impact on the riskiest of behaviors: injection-drug use. The first clean-syringe access programs in the mid-1980s came about as researchers discovered the link between injection-drug use and HIV, and realized that a lack of access to clean needles exacerbated the transmission of infectious diseases. More recently, naloxone-distribution programs are being promoted as a response to dramatic increases in opioid overdose deaths. The decreased incidence of both HIV and overdose fatalities following the implementation of these programs, as well as decreases in related-disease transmission and increased entry into treatment, lend proof of harm-reduction’s effectiveness.

Like providing injection-drug users with clean needles, encouraging smokers to switch to e-cigarettes (or, if approved, heat-not-burn alternatives) without forcing abstinence on those who don’t want to quit will help reduce the incidence of smoking-related illness and death. This is the very essence of harm reduction. By accepting that we are highly unlikely to realize a world where no child or adult is exposed to tobacco or opioids, harm-reduction approaches can have a positive impact on the health and welfare of our society.

Critics of harm reduction are quick to list the toxins present in e-cigarettes – formaldehyde, acetaldehyde, acrolein, and propylene glycol. And of course, it’s impossible to defend e-cigarettes as completely safe. But the comparison of toxins contained in cigarettes and those in nearly every other product will show that the relative risk (that is, the risk of e-cigarettes or other products compared to combustibles) is much lower.

To fight the societal harms of smoking, we must embrace new technology that offers reduced-risk alternatives to the most dangerous form of nicotine delivery: the combustible cigarette. That includes products that may come from the reviled tobacco industry itself.

Unfortunately, dangerous behaviors will always be a part of our society. Human nature guarantees this, and for tobacco, both domestic and international agreements ensure that combustible cigarettes will always be readily available. As such, policymakers must adopt the most effective strategies to protect our populace from the most dangerous outcomes of tobacco use. As such, harm-reduction approaches to smoking offer a promising option to explore.


Image credit: Ilkin Zeferli

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